What does it take to put prescription checkups into practice?
If you have seen our action plan to eliminate medication overload, you know that a crucial part of reducing medication-related harm is giving clinicians and patients more opportunities to deprescribe (discontinue or reduce doses of medications).
That’s why our Medication Overload Working Group recommended prescription checkups: medication reviews designed specifically for the purpose of removing unnecessary or harmful medications. At a prescription checkup, the patient and clinician (and caregivers or family members as necessary) review all the
medications the patient is taking and discuss the benefits and harms of each, with the goal of reducing the patient’s medication burden and risk of harm.
Prescription checkups have the potential to encourage appropriate deprescribing for the millions of older adults at risk of medication overload. However, conducting prescription checkups in practice is more difficult than in theory. What does it take to implement prescription checkups in the real world?
In a recent Health Affairs blog, Lown Institute senior vice president Shannon Brownlee, and two members of the Lown Institute’s working group on medication overload–medical director for pharmacy for the Permanente Medical Group Maisha Draves, and regional clinical operations manager at Kaiser Permanente Lynn Deguzman–explain how Kaiser Permanente implemented prescription checkups for older patients, and the effect of the program on health outcomes.
Why prescription checkups?
As Brownlee et al. write, there are several types of medication reviews that are commonly used, such as medication therapy management (MTM), but so far these have not resulted in widespread deprescribing. This is partly because the MTM process is not focused on removing medications for patients beyond those specified in the Beers Criteria. Also, clinicians conducting MTMs are not usually paid enough to spend the time they need discussing the benefits and harms of medications with patients in the context of their particular values and goals.
Prescription checkups, however, are focused on deprescribing whenever possible, by engaging patients and caregivers in shared decision making conversations about their medications. By “moving appropriate deprescribing to the forefront of care,” we can build on existing medication reviews and improve outcomes, the authors write.
Prescription checkups at Kaiser Permanente
Draves and Deguzman have led Kaiser Permanente’s deprescribing initiatives, which began in 2016 with a program to deprescribe specific medications in older adults such as NSAIDs, diabetes medications, and blood pressure medications.
Kaiser’s deprescribing program helped nearly 700 older patients reduce medication overload, decreasing their risk of low blood sugar and all-cause mortality, and increasing patients’ adherence to their other medications.
Making this initiative a success required considerable coordination, planning, and education. Family physicians, pharmacists, specialists, and researchers all had to work together to identify areas for deprescribing, develop protocols, and identify appropriate patients for deprescribing. Having pharmacists as part of the care team, an integrated electronic health record for all providers, and constant communication between providers were crucial elements as well.